Presentation on theme: "Musculoskeletal Dysfunction In The Athlete (The Shoulder)"— Presentation transcript:
1 Musculoskeletal Dysfunction In The Athlete (The Shoulder) John M. Lavelle DOSpine Physiatrist
2 Shoulder Dysfunction Is there a Somatic Component? Very common in the athlete.Pain, weakness and limited mobility overheadLocal extremity dysfunction, axial skeletal problem or combination of both.Orthopeadic problem –Tendonitis, Impingement, RTC tear, Hill-Sachs deformity, Dislocation, etcIs there a Somatic Component?Hill-sachs: posterolateral head of humerus from continuous dislocation or bankhart lesion (inf. Labral tear)Somatic Dysfunction : impaired of function of bodily structures, most often of the msk, nervous, or lymphatic system, diagnosed clinically by TARt.
3 AnatomyShoulder:Mobile joint with a shallow glenoid fossa.Minimal osseous support.Joint of greatest mobility, thus joint of greatest instability.Four joints: Scapulothoracic, Acromioclavicular, Glenohumeral, SternoclavicularRestriction in any one of these can alter proper shoulder mechanicsAssess them all for any restrictions in motion.RTC:Supraspinatous, infraspinatous, subscapularis, teres minorSupraspinatous torn in approx 90% of RTC tendonitis cases
4 Main Shoulder Motions Adduction Abduction Flexion Extension Int. Rot CoracobrachialisSupraspinatousCoraco-brachialisLat dorsiSubscapInfra-spinatousPec MajorMid DeltiodAnt DeltoidPost DeltoidTeres MinorTeres Major
5 History Sport How long season?, Level of play?, Equipment? Pitching, GolfRock climbingTennisGymnasticsHow long season?, Level of play?, Equipment?Why presenting now?: Improving?, Same?, Worse?FOOSH injury/Collisions/Trauma - MacrotraumaRepetitive Overuse (lifting, bending, twisting, etc)Microtrauma
6 Thoracic DysfunctionSomatic dysfunction of the thoracic spine/ribs may produce shoulder symptomsExtended Type II dysfunction commonSegmental dysfunction alters the scapular stabilizing muscles, affecting the gliding movement of the scapula over the thoracic cage.Only the first 20-30° of shoulder abduction occurs without scapulothoracic motion.RTC muscles become irritable and tenderThe sympathetic autonomic outflow for the UE/neck: T1-T4.Somatic dysfunction in this region can lead to increased stimulation of the sympathetics.
7 Cervical Dysfunction The cervical spine also affects the shoulder. C5-C8 nerve roots exit the c-spine thru intervertebral foraminae and coalesce in the brachial plexus - innervates the UE.Somatic dysfunction of the neck.Impingement at the nerve root.Compression at the brachial plexus.Anterior and middle scalenes, first rib and/or clavicular dysfunction, and myofascial strainRTC patients tend to “hike” shoulder:Scalene hypertonicity, upper trap tender points, type II cervical dysfunction, elevated 1st rib, T1 dysfunction
8 Latissimus DorsiConnection between the pelvis and the UE through latissimus dorsi muscle.Attaches to the iliac crest, the spinous processes of the lumbar and lower thoracic vertebrae and the bicipital groove.In addition, this muscle often attaches to the inferior angle of the scapula as it passes over the scapula.Somatic dysfunction at the thoracolumbar junction can lead to dysfunction of the UE.
9 Functional Examination Orthopeadic pathology vs Functional conditionsEvaluate performing sport specific movementMusculoskeletal compensationsnormal vs abnormalConsider center of gravity, ground reaction forces, muscle firing patterns and postural patterns
10 Osteopathic Exam Observation: Osteopathic standing structural exam. Any asymmetry by comparing the mastoid process, AC joint, spine of the scapula and inferior angle of the scapula bilaterally.Muscle wasting? - focusing on the supraspinatous, infraspinatous, trapezius, deltoid muscles, rhomboids, biceps, triceps and levator scapulae muscles.AROM: look at cervical’s and shoulder for restrictions
11 Osteopathic Exam Palpation: Compare both shoulders - healthy shoulder first.Palpate the c-spine - restrictions of movement in PROMAny segmental, Fryette type II, restrictions in the c-spine.Palpate the thoracic spine - any somatic dysfunction within the thoracic vertebrae, ribs or musculature.Remember that somatic dysfunction in this area will affect scapulothoracic motion and thus the motion of the entire shoulder joint.
12 Osteopathic Exam Palpation: Along supraspinatous and infraspinatous musclesSubscapularis muscle tender pointPlace your palpating finger anterior to the posterior axillary fold and palpate the anterior boarder of the scapula.Biceps tendonPlace the patients hand in supination and arm in external rotation to open the bicipital groove and palpate along the biceps tendon for tenderness.Any medial scapular winging - weakness in the serratus anteriorAsk the patient to elevate/flex the arm as you depress the arm with one hand and palpate the scapula with the other.
14 Shoulder Exam PROM MMT Special Tests… shoulder flexion, extension, abduction, adduction, internal and external rotation.MMTAll planesSpecial Tests…Neer, Drop arm, Empty can, Hawkins, O’Brien, Apley scratch, Lift-off, Speed’s, Yergason’s, Sulcus sign, Apprehension, Relocation test
15 OMT Shoulder: Acute – treat distant yet related areas Start with upper thoracics, rib and c-spineStay away from painful arcs of motionPostural exercises, scapular stabilization, core strengthening – then shoulder strengthening.Indirect techniques until ROM improvesAcute – treat distant yet related areasChronic – treat key somatic dysfunctionRemember phases of healing“aggressive conservatism”
16 Conclusion Clincal exam/history gives you most of the information. Further work-up with radiographs.Reserve MRI/Electrodiagnostics for when diagnosis is equivocal, management is in question or surgery is considered.Begin treatment with conservative measuresOMT, NSAIDS, physical therapy.
17 Thank You!References:Nelson KE. Somatic Dysfunction in Osteopathic Family Medicine. LWW, Baltimore MD, 2007:Malanga GA. Musculoskeletal Physical Examination. Elsevier, Philadelphia PA, 2006:Griffin LY. Essentials of Musculoskeletal Care . AAOS, 2005:
18 Myofascial Release (MFR): Scapulothoracic Release Technique Kristin Garlanger OMS III, OMM FellowChicago College of Osteopathic Medicine
19 Scapulothoracic Release Technique Dysfunction: Restricted motion of the left scapula on the thoracic cageObjective: Improve scapular motionDiscussion: This technique can be use for both evaluation and treatment Patient Position: The patient lies on his/her right side with the affected side up. The patient’s hips and knees are flexed (for stability) and a small pillow is placed under his/her head for comfort.Physician Position: The physician stands along side the table facing the patient. Procedure:Drape the patients left arm over your right shoulderContact the patient’s medial scapular border with your fingertips. Take one step back with your caudad foot for increased stability.Control the scapula with both hands and gently assess its full range of motion. Keep in mind the muscular restrictions that would cause a loss of motion.Restriction in motion can be relieved by: a. Holding against a barrier with traction (load and hold) b. Holding in a position of ease (unload and follow) c. ROM/ stretching or articulating against the barrierReassess the scapulothoracic motion and treat any remaining restrictions.
20 Pratik Shah OMS IV, OMM Fellow Chicago College of Osteopathic Medicine HVLA: Knee in the BackPratik Shah OMS IV, OMM FellowChicago College of Osteopathic Medicine
21 Knee in back flexed dysfunction Knee in back extended dysfunction Knee is on segment below on opposite side of dysfunctionKnee is on the dysfunctionKey Considerations:Don’t grasp wrists too firmlyAlways use a pillowTechnique is most effective for T2-T6Keep weight balanced over the ischial tuberositiesEngage the barrier with lateral translation primarily
22 Treating Rib Dysfunction with Functional Technique Paula Ackerman OMSV, OMM FellowOhio University College of Osteopathic Medicine
23 Treatment 1. Patient is lateral recumbent 2. Physician stands in front of patient3. Arm supported cephalad to elbow4. Unsupported elbow hangs toward the floor5. Physician monitors at rib angle6. Motion input is through upper extremity7. Monitor increasing ease through “stacking”motion8. Following successful release, return to midline and re-test